DSM 5 - Revising the reality of mental illness?

Psychiatrists Revise the Book of Human Troubles

By Benedict Carey

December 18, 2008

The book is at least three
years away from publication, but it is already stirring bitter debates over a
new set of possible psychiatric disorders. Is compulsive shopping a mental
problem? Do children who continually recoil from sights and sounds suffer from
sensory problems — or just need extra attention? Should a fetish be considered
a mental disorder, as many now are?

Proposed changes in the
definition of autism would sharply reduce the skyrocketing rate at which the
disorder is diagnosed and might make it harder for many people who would no
longer meet the criteria to get health, educational and social services, a new
analysis suggests. The definition is now being reassessed by an expert panel
appointed by the American Psychiatric Association, which is completing work on
the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders,
the first major revision in 17 years. The D.S.M., as the manual is known, is
the standard reference for mental disorders, driving research, treatment and
insurance decisions. Most experts expect that the new manual will narrow the
criteria for autism; the question is how sharply. The results of the new
analysis are preliminary, but they offer the most drastic estimate of how
tightening the criteria for autism could affect the rate of diagnosis. For
years, many experts have privately contended that the vagueness of the current
criteria for autism and related disorders like Asperger syndrome was
contributing to the increase in the rate of diagnoses — which has ballooned to
one child in 100, according to some estimates.

When does a broken heart
become a diagnosis? In a bitter skirmish over the definition of depression, a
new report contends that a proposed change to the diagnosis would characterize
grieving as a disorder and greatly increase the number of people treated for
it.The new report, by psychiatric
researchers from Columbia and New York Universities, argues that the current
definition of depression — which excludes bereavement, the usual grieving after
the loss of a loved one — is far more accurate. If the “bereavement exclusion”
is eliminated, they say, “there is the potential for
considerable false-positive diagnosis and unnecessary treatment of
grief-stricken persons.” Drugs for depression can have side effects, including
low sex drive and sleeping problems. But experts who support the new definition
say sometimes grieving people need help. “Depression can and does occur in the
wake of bereavement, it can be severe and debilitating, and calling it by any
other name is doing a disservice to people who may require more careful
attention,” said Dr. Sidney Zisook, a psychiatrist at
the University of California, San Diego.

…The D.S.M. is the
offspring of odd bedfellows: the medical industry, with its focus on germs and
other biochemical causes of disease, and psychoanalysis, the
now-largely-discredited discipline that attributes our psychological suffering
to our individual and collective history….The American Psychiatric Association
has been…leaving behind ideas about the meaning of our suffering in favor of
observation and treatment of its symptoms. In 1980, it hit on the strategy of
adopting a medical rhetoric, organizing those symptoms into neat disease
categories and checklists of precisely described criteria and publishing them
in the hefty — and, according to its chief author, “very scientific-looking” —
D.S.M.-III.

But as all those
Diagnostic and Statistical Manuals have stated clearly in their introductions,
while the book seems to name the mental illnesses found in nature, it actually
makes “no assumption that each category of mental disorder is a completely
discrete entity with absolute boundaries dividing it from other mental
disorders or no mental disorder.” And as any psychiatrist involved in the making
of the D.S.M. will freely tell you, the disorders listed in the book are not
“real diseases,” at least not like measles or hepatitis. Instead, they are
useful constructs that capture the ways that people commonly suffer….

… With the DSM-III,
biomedical investigators replaced clinicians as the most influential voices in
the field. Even though few of those involved in Spitzer’s task force were
associated with work on psychopharmacology or the biology of mental disorders,
the biological default in what they proposed came about as one of the
assumptions of neo- Kraepelinians—that the core symptoms of mental disorders
stemmed from some form of brain malfunctioning. Consequently, psychotherapy
became the primary domain of clinical psychologists, counselors, and social
workers, who appeared to practice it as effectively as psychiatrists but who
charged less. Psychopharmacological therapy became the private “turf ”of medically trained psychiatrists.

…

The publication of the
DSM-III in 1980 caused a revolution in psychiatry. It also triggered a paradigm
shift in how society came to view mental health. Prior to the DSM-III, psychiatrists
primarily targeted the underlying psychological causes of mental illness and
disorder with psychotherapy. Alternative approaches, such as behavioral
therapy, were subordinated to the dominance of psychodynamic theory and
practice. With the DSM-III, they gradually shifted to primarily targeting the
symptoms of mental illness and disorder with psychopharmacology, the use of
drugs to treat mental ills. The direct and indirect institutional change the
new manual produced extended far beyond psychiatry, because the DSM is used by
clinicians, the courts, researchers, insurance companies, managed care
organizations, and the government (NIMH, FDA, Medicaid, Medicare).
As a classificatory scheme, it categorizes people as normal or disabled,
healthy or sick. And as the definitive manual for measuring and defining
illness and disorders, it operates as mental health care’s official language
for clinical research, financial reimbursement, and professional expertise. Few
professional documents compare to the DSM in terms of affecting the welfare of
so many people.

The DSM-III’s creation was not the result of a
carefully orchestrated conspiracy, but neither was it an accident or
“chance-like sequence” of events as some have argued. It did not stem from any
new knowledge about the causes of mental illnesses nor their treatments. In
addition, it did not enlarge the realm of behaviors that the psychiatric
profession was to treat. Instead, its symptom-based focus stemmed from the
efforts of research-oriented psychiatrists who wanted to standardize diagnostic
criteria and focus attention on the symptoms of mental disorders, rather than
on their underlying causes…

The struggle over the drafting and publication
of the DSM-III appeared to be a clinical debate among psychiatrists, but
underlying it all was a vehement political struggle for professional status and
direction. “DSM-III is a political document in many ways,” observed Gerald
Klerman. “It appeared in response to some of the ideological and theoretical
tensions within the profession of psychiatry. It also has been caught up in the
rivalries and tensions among the various mental health
professions—psychiatrists, social work, psychology”.

Finally, while the DSM-III standardized the
diagnostic classification scheme for mental illnesses and disorders, it did not
include treatment guidelines. By virtue of its Kraepelinian orientation,
however, it allowed pharmaceutical companies to market their products for a
growing number of specific, symptom-based disease entities. The DSM-III
unintentionally positioned psychopharmacology on a growth trajectory that
various institutions—insurance companies, managed care organizations,
pharmaceutical companies, and the government—propelled significantly in
subsequent years as they responded to the DSM-III’s new diagnostic guidelines
and the research incentives that it fostered.